Hormone treatments can throw up a host of physical challenges for people when they’re transitioning. Dr A Bolin  looks at a few of the more common ones and gives some hints on how to handle them.

There’s no doubt it’s a long hard road to travel when your considering a male-to-female (MTF) or female-to-male (FTM) transition, and it doesn’t end once you’ve made the decision. Hormone therapies present a number of physical challenges and the goal of this article is to give a general overview of the changes that may occur with hormone treatments.  After making the decision to start hormonal treatment, one must be aware of the risks, expectations, long term considerations, and medications associated with the transition from male to female or female to male.

Usually there is a support team in place to ensure medical monitoring and professional or peer counselling throughout the process which can take several years.  Some people hope to achieve faster results by self-medicating and obtaining medication from friends or purchasing them from the internet or off the street.  But it is always recommended to be monitored by a prescribing physician and their team in order to ensure correct dosage and quality of medications,  as well as symptom management.  It is important to note that hormone therapy has an impact not only physically, but also emotionally and on sexual drive and fertility.

MALE TO FEMALE TRANSITION (MTF)

For male-to-female (MTF) transition, the following hormones may be used as treatment: oestrogens, finasteride, spironolactone (testosterone blocker), and gonadotropin-releasing hormone (GnRH) analogs.  Surgical procedures may address genital reconstruction, changes to facial structure, breast enhancement, etc.

Oestrogen is the dominant hormone for feminisation that may be administered orally (a pill), by injection, or by topical absorption (such as a patch or creams/gels on the skin).

Side effects may include mood changes or hot flushes.  Liver function and cholesterol monitoring and screening for diabetes are all important during treatment.

EYES AND FACE

It can take several years for the hormonal changes to change the appearance of your face due to fat redistribution.  Bony structure will not change without surgical intervention.

SKIN

Your skin should become softer over time and might become thinner.  There should be a decrease in oil production as well as sweat. It may be more sensitive to touch, temperature, and pain.

Tips for your skin care regimen:

• As oestrogen levels will be elevated, uneven skin pigmentation can occur on the face (like in pregnancy, melasma “mask of pregnancy”).
• Hydroquinone can help with evening out the skin (speak with your dermatologist to discuss if it is the right choice for you).
• If you find your skin is rough, retinoid derivatives (vitamin A) may be used topically to promote skin cell turnover as well as collagen and elastin production. The retinoids tend to lead to smoother skin.
• Alpha-hydroxy acids such as glycolic acid and beta-hydroxy acids like salicylic acid can unblock pores and have an exfoliating effect.
• It is important to choose the best product for you and to not use harsh scrubs or abrasive cleansers.
• Remember that all these products will increase your sensitivity to the sun, so using sunscreen is a must.

FACIAL AND BODY HAIR

The amount of body and facial hair should decrease with time and may become more fine.  It still may be necessary to wax, shave, or to consider more permanent hair removal solutions such as laser hair removal or electrolysis.  Male-pattern balding should occur at a slower rate (depending on genetics).  Hair transplants are costly but can be considered if growing your hair does not achieve the desired pattern or thickness desired.  Minoxidil is a topical solution that can stimulate hair growth and may also be of help.

Tips for your hair removal regimen:

• For permanent hair removal, an investment of time, patience and money (depending on which type of treatment you choose) is needed.
• Electrolysis and laser hair removal are very effective long-term solutions.
• Take care how long sessions are and decrease treatments (or amount of time spent per session) based on side effects of redness, sensitive skin and swelling.
• Shaving should be avoided when possible since it can also irritate the skin and does not address the roots of the hair follicles.
• Avoid harsh toners, astringents and any product that stings on contact with your skin. Aloe vera gel is soothing, just avoid formulations that contain alcohol, as these may irritate your skin.

VOICE

The hormones do not change the voice.  In order to achieve a higher pitch, inflection, etc. voice therapy is essential.  If the result achieved is not as desired, surgical options to alter the vocal cords may be considered.

MUSCLES

It would be expected to decrease over time with less definition.

FAT DISTRIBUTION

Over several years, the fat will re-distribute to more of a “pear shape”, with buttocks, hips, and thighs sequestering more of the fat.

FEET

The ligaments of the feet may stretch out, making minor changes to the shape of the foot.

BREASTS

Breast tissue normally takes 2 years to achieve the full size.  At the beginning, the nipples will become sensitive and may be a bit sore as the breast tissue continues to develop.   The areola (area around the nipple) and nipple may enlarge in size also.  It is rare for the breasts to be larger than a size B cup due to hormone treatment.

PROSTATE

The prostate will decrease in size with time.

GENITALS 

The testes and penis will decrease in size as will the production of sperm. Some individuals opt for orchiectomy (surgical removal of testes).  If they have this procedure, much less oestrogen is needed.

INFERTILITY/IMPOTENCE

Erections may become weaker and less frequent or may not occur at all, as well as decreased volume of ejaculate.  However, note that many women describe feeling more satisfied with their orgasms in spite of the above physical and physiological changes.

SPERM BANKING

If the individual wishes to consider having children in future, it is ideal to consider banking sperm before any treatments begin.  Also, depending on the stage of treatment, if sexually active with a woman, contraception should be used to prevent unwanted pregnancy.

FEMALE TO MALE TRANSITION (FTM)

Patients who choose to undergo female-to-male (FTM) transition would take testosterone and GnRH analogs.  Surgical options might include breast reduction (mammoplasty) and Plastic surgery performed to construct, repair, or enlarge the penis (phalloplasty).

Testosterone is the main hormone that may be administered orally (a pill, in some countries), by injection, or by topical absorption (such as a patch or creams/gels on the skin).  Side effects may include.  Monitoring of cholesterol, blood pressure, blood glucose (decreased insulin sensitivity), and weight are all important during treatment.

SKIN

Testosterone tends to lead to more oil production and increased acne.

Tips for acne:

• It is important to take good care of your skin and avoid scarring.
• Don’t wash your face too frequently (not more than twice a day), as it can irritate the skin.
• Don’t squeeze and prod closed blackheads, whiteheads, bumps (papules or pustules) or cysts (goal: avoid inflammation and scarring).
• Use make-up that doesn’t block pores (non-comedogenic).
• Ensure make-up removal before bed.
• Topical treatment with these medications may help unblock pores: retinoids, benzoyl peroxide and azelaic acid. Some of these are associated with increased sensitivity to UV rays, so make sure to use a good sunscreen.
• Topical antibiotics may be useful, and if topical medications are not working appropriately, oral antibiotics may be prescribed.

Tips for acne scarring:

• Dermabrasion can help slough off dead skin cells which may lead to new collagen production, improving the appearance of the skin surface (and scars) over time.
• Laser treatments: some lasers remove surface layers of skin and others stimulate collagen production.
• Various surgical options may be considered if the scars are very deep.
• Fillers can help with decreasing the appearance of scars.
• Speaking with a dermatologist to match the best treatment for your skin type is always recommended.

FACIAL AND BODY HAIR 

It is expected that body hair become more dense and facial hair grows with time (hirsutism).

VOICE

Testosterone has an effect on the pitch of the voice (lower).  However, speech patterns and intonation will need to be addressed by a speech therapist. Also, the larynx (throat region) tends to become more visibly pronounced.

MUSCLE MASS

It is expected to develop more muscle mass and to be more well defined.

FAT DISTRIBUTION

One can expect to gain weight.  Fat will tend to distribute more around the abdomen in an “apple-shape” pattern.

BONE

If the ovaries are removed, it is a concern to have decreased bone mineral density.  Hence, it is important to follow guidelines for DEXA scans and vitamin D/calcium supplementation.

BREASTS

Breasts may slightly decrease in size but will not disappear.  Surgical intervention may assist with removing the excess breast tissue (breast reduction).

OVARIES AND UTERUS

It would be expected for menstruation to stop.  However, if not, depo-provera (injectable progesterone) may help.

GENITALS 

The clitoris can increase in size and length (several centimetres).  It is important to use contraception (condom, diaphragm, etc.) since testosterone is not recommended during pregnancy (toxic).  Also, the vagina may be less lubricated and the lining may be more prone to tear. Lubricants are recommended.

LIBIDO

Testosterone is associated sometimes with an increase in libido (sex drive).

MOOD

If increased aggression due to injected testosterone treatment, one can consider a patch for transdermal absorption that might be a better option.

INFERTILITY

Normally testosterone treatment results in infertility.  However, it is advisable to use contraception until advised otherwise by a healthcare provider.

EGG BANKING

If the individual wishes to consider having children in future, it is ideal to consider freezing eggs before any treatments begin.  Also, depending on the stage of treatment, if sexually active with a man, contraception should be used to prevent unwanted pregnancy.

Further Resources:

http://www.nhs.uk/Livewell/Transhealth/Pages/Transhealthhome.aspx

http://gendertrust.org.uk/directory/support-organisations

A Guide to hormone therapy for trans people http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF